• Angular deformities of LL:– Bow legs.– Knock knees.
• Rotational deformities of LL:– In-toeing.– Ex-toeing.
• Leg aches.• CDH.• Feet problems.• Irritable hip.
Common Orthopedic Problemsin Children
Angular LL Deformities of LL
Angular DeformitiesNomenclature
Bow legs Knock knees
Genu Varus Genu Valgus
Angular DeformitiesRange of Normal Varies With Age
• During first year : Lateral bowing of Tibiae
• During second year : Bow legs (knees & tibiae)
• Between 3 – 4 years : Knock knees
Angular DeformitiesEvaluation
Should differentiate between
“physiologic” and “pathologic”deformities
Angular DeformitiesEvaluation
Physiologic Pathologic
• Expected for age• Generalized• Regressive
• Mild – moderate
• Symmetrical
•Not expected for age
• Localized
• Progressive• Severe
• Asymmetrical
Angular DeformitiesCauses
Physiologic Pathologic
- Use of walker? - Early wt. bearing - Overweight
• Exaggerated :
• Normal – for age
• Idiopathic
• Injury to Epiphys. Plate Infection / Trauma
• Metabolic disease• Endocrine disturbance
• Rickets
Angular DeformitiesEvaluation
Symmetrical deformity
Angular DeformitiesEvaluation
Asymmetrical Deformity
Angular DeformitiesEvaluation
Generalized deformity
Angular DeformitiesEvaluation
Localized deformity
Blount’s
Angular DeformitiesEvaluation
Rickets
Localized deformity
in bow legs / genu varum
Inter-condylar distance
Measure Angulation( standing / supine )
Angular DeformitiesEvaluation
in knock knees /genu valgum
Inter- malleolar distance
Measure Angulation( standing / supine )
Angular DeformitiesEvaluation
Measure Angulation
Angular DeformitiesEvaluation
Use goneometermeasures angles directly
• Serum Calcium / Phosphorous ?• Serum Alkaline Phosphatase• Serum Creatinine / Urea – Renal function
Angular DeformitiesEvaluation
Investigations / Laboratory
X-ray when severe or possibly pathologic
• Standing AP film– long film ( hips to ankles ) with patellae directed forwards
• Look for diseases :– Rickets / Tibia vara (Blount’s) / Epiphyseal injury..– Measure angles.
Angular DeformitiesEvaluation
Investigations / Radiological
Femoral-Tibial AxisMedial Physeal Slope
Angular DeformitiesEvaluation
Investigations / Radiological
Angular DeformitiesWhen To Refer ?
• Pathologic deformities: Asymmetrical. Localized. Progressive. Not expected for age.
• Exaggerated physiologic deformities: Definition ?
Angular DeformitiesSurgery
Rotational LL Deformities
• Frequently seen.• Concerns parents.• Frequently prompts varieties of treatment.
( often un-necessary / incorrect )
In-toeing / Ex-toeing
Rotational Deformities
• Level of affection : Femur Tibia Foot
Rotational DeformitiesFemur
Ante-version = more medial rotationRetro-version = more lateral rotation
Rotational DeformitiesNormal Development
• Femur : Ante-version :– 30 degrees at birth.– 10 degrees at maturity.
• Tibia : Lateral rotation :– 5 degrees at birth.– 15 degrees at maturity.
Rotational DeformitiesNormal Development
Both Femur and Tibia laterally rotate with growth in children
• Medial Tibial torsion and Femoral ante-version improve ( reduce ) with time.
• Lateral Tibial torsion usually worsens with growth.
Rotational DeformitiesClinical Examination
Rotational Profile
• At which level is the rotational deformity?• How severe is the rotational deformity?• Four components: 1- Foot propagation angle. 2- Assess femoral rotational arc. 3- Assess tibial rotational arc. 4- Foot assessment.
Rotational DeformitiesClinical Examination
Rotational Profile
1- Foot propagation angle – Walking
Normal Range:+10o _10o
? In Eastern Societies+25o _10o
Rotational DeformitiesClinical Examination
Rotational Profile 2- Assess Femoral Rotational Arc
SupineExtended
Rotational DeformitiesClinical Examination
Rotational Profile 2- Assess Femoral Rotational Arc
Supineflexed
Rotational DeformitiesClinical Examination
Rotational Profile3- Tibial Rotational Arc
Thigh-foot angle in prone
foot position is criticalleave to fall into natural
position
Rotational DeformitiesClinical Examination
Rotational Profile 4- Foot assessment
• Metatarsus adductus• Searching big toe• Everted foot• Flat foot
• Out-toeing : Normal• seen when infant positioned upright
( usually hips laterally rotate in-utero )
• Metatarsus adductus :• medial deviation of forefoot• 90 % resolve spontaneously• casting if rigid or persists late in 1st year
Rotational DeformitiesCommon Presentations
Infants
Rotational DeformitiesCommon Presentations
Toddlers
• In-toeing most common during second year. ( at beginning of walking )• Causes :
– medial tibial torsion.– metatarsus adductus.– abducted great toe.
Rotational DeformitiesCommon Presentations
Toddlers - Medial Tibial Torsion
• The commonest cause of in-toeing• Observational management is best• Avoid special shoes / splints / braces
– unnecessary, ineffective, interferes with activity and cause psychological and behavioral problems.
Rotational DeformitiesCommon Presentations
• Serial casting is effective in this age-group• Usually correctable by casting up to 4 years
Toddler - Metatarsus Adductus
Rotational DeformitiesCommon Presentations
• Dynamic deformity• Over-pull of Abductor
Hallucis Muscle during stance phase
Toddlers - Abducted Great Toe
• Spontaneously resolve - no treatment
Rotational DeformitiesCommon Presentations
Child
• In-toeing : due to medial femoral torsion
• Out-toeing : in late childhood lateral femoral / tibial torsion
Rotational DeformitiesCommon Presentations
ChildMedial Femoral Torsion
• Usually: - starts at 3 - 5 years, - peaks at 4 – 6 years, - then resolves spontaneously.• Girls > boys.• Look at relatives - family history – normal.• Treatment usually not recommended.• If persists > 8 years and severe, may need surgery.
Rotational DeformitiesCommon Presentation
• Stands with knees medially rotated (kissing patellae).• Sits in W position.• Runs awkwardly (egg-beater).
Family History
Medial Femoral Torsion (Ante-version)
Rotational DeformitiesCommon Presentations
ChildLateral Tibial Torsion
• Usually worsens.• May be associated with knee pain (patellar) specially if LTT is associated with MFT. ( knee medially rotated and ankle laterally rotated )
Rotational DeformitiesCommon Presentations
ChildMedial Tibial Torsion
• Less common than LTT in older child
• May need surgery if :– persists > 8 year,– and causes functional disability
Rotational DeformitiesManagement
• Challenge : dealing effectively with family
• In-toeing : spontaneously corrects in vast majority of children as LL externally rotates with growth - Best Wait !
Rotational DeformitiesManagement
Convince family that only observation is appropriate
• < 1 % of femoral & tibial torsional deformities fail to resolve and may require surgery in late childhood.
Rotational DeformitiesManagement
• Attempts to control child’s walking, sitting and sleeping positions is impossible and ineffective cause frustration and conflicts.
• She wedges and inserts : ineffective.• Bracing with twisters :ineffective - and limits activity.• Night splints : better tolerated - ? Benefit.
Rotational DeformitiesManagement
Shoe wedges Ineffective Twister cables Ineffective
Rotational DeformitiesWhen To Refer ?
• Severe & persistent deformity.• Age > 8-10y.• Causing a functional dysability. • Progressive.
Rotational DeformitiesManagement
When Is Surgery Indicated ?
•In older child ( > 8 – 10 years ).
•Significant functional disability.
•Not prophylactic !
Leg Aches / Growing Pains
Leg Aches / Growing Pains
• Incidence : 15-30 % of children.• More In girls / At night / In LL.• Diagnosis is made by exclusion.
Leg Aches / Growing PainsHistory
• Vague pain.• Poorly localised.• Bilateral.• Nocturnal.• Seldom alters activity.• Long duration.
Leg Aches / Growing PainsExamination
• General health is normal.• No deformities.• No joint stiffness.• No tenderness.• Normal gait.• No limping.
Leg Aches / Growing PainsManagement
• When atypical history or signs present on examination:– Imaging and lab. Studies.
• If all negative :– Symptomatic treatment :
• Heat / Analgesics.– Reassure family :
• Benign.• Self-limiting.• Advise to re-evaluate if clinical features change.
Leg Aches / Growing Pains
Feature Growing Pain Serious Problem
History : Long duration Often Usually not Pain localised No Often Pain bilateral Often Unusual Ulters activity No Often Cause limping No Sometimes General health Good May be ill
From Stahili : Practice of Pediatric Orthopedics 2001
Leg Aches / Growing Pains
Feature Growing Pain Serious Problem
Physical examination : Tenderness No May show Guarding No May show Reduced rang of motion No May showLaboratory : CBC Normal ? Abnormal ESR Normal ? Abnormal
From Stahili : Practice of Pediatric Orthopedics 2001
CDH / DDH
Congenital Dislocation of Hip.Developmental Dysplasia of Hip.
CDH Spectrum
• Teratologic Hip : Fixed dislocation Often with other anomalies• Dislocated Hip : Completely out May or may not be reducible• Subluxated Hip : Only partially in• Unstable Hip : Femoral head can be dislocated• Acetabular Dysplasia : Shallow Acetabulum Head Subluxated or in place
CDHEtiology & Risk Factors
• Prenatal : – Positive family history (increases risk 10X)– Primi-gravida– Female (4-6 X > Males)– Oligo-hydramnious– Breech position (increases risk 5-10 X)
• Postnatal : – Swaddling / Strapping ( ? Knees extended)– Ligament Laxity– Torticollis (CDH in 10-20 % cases)– Cong. Knee recurvatum / dislocation– Metatarsus adductus / calcaneo-valgus
CDH Risk Factors
When Risk Factors Are Present
• The infant should be examined repeatedly
• The hip should be imaged by– U/S– or X-ray
CDHClinical Examination
CDHNeonatal Examination
LOOK :• Asymmetric thigh
folds– Posterior– anterior
CDHClinical Examination
Look :• Shortening ( not in neonates )
- Galeazzy sign- in supine
CDHNeonatal Examination
MOVE :• Hip instability in early infancy• Limited hip abduction
in flexion - later• (careful in bilateral) if <600 on both sides: request imaging
CDHNeonatal Examination
CDHNeonatal Examination Hip Flexion Deformity
SPECIAL :• Loss of fixed flexion
deformity of hips in early infancy.
• Normally FFD:– newborn 28o
– at 6 weeks 19o
– at 6 months 7o
NormalFFD
CDHNo FFD
Thomas Test
CDHNeonatal Examination
Ortolani Barlow
Feel ClunkNot hear click !
CDHNeonatal Examination
Ortolani / Barlow
clunk
Ortolani Barlow
CDHNeonatal Examination
Ortolani Test Barlow Test
CDHClinical Examination
• Hip clicks : - fine, short duration, high pitched sounds - common and benign – from soft tissues• Hip clunks : - sensation of the hip displacing over the acetabular margin • If in doubt : U/S in young infants single radiograph if > 2-3 months
CDHClinical Examination
• Neonate (up to 2-3 months) :– Instability/ Ortolani-Barlow
• Infant ( > 2-3 months) :– Limited abduction– Shortening ( Galeazzi )
• Toddler :– Limited abduction– Shortening ( Galeazzi )
• Walker :– Trendelenburgh limpimg
CDHUltrasound Screening
• Early U/S screening not recommended• Delayed U/S screening :
– Older than 3 weeks– Those at risk or suspicious by:
• History• Clinical exam
CDHTreatment
• Birth to 6 months :– Pavlik harness or hip spica cast
• 6 months – 12 months :– closed reduction UGA and hip spica casts
• 12 months – 18 months :– possible closed / possible open reduction
• Above 18 months :– open reduction and ? Acetabuloplasty
• Above 2 years :– open reduction,acetabulplasty, and femoral osteotomy
CDH
Treatment
• Method depends on Age• The earlier started, the easier the treatment
& the better the results• Should be detected EARLY• UREGENT referral once an abnormality is
detected.
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